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9.07.2005

yearly ritual

here's my long case on Tee as we'll call her. poor little girlie had to celebrate her 6th bdae at the hospital. apparently, she celebrated her 5th bdae at the hospital with a broken collarbone last year. ian joked that we should book her in for the same time next year at this rate, hee.

Sooo...

I saw Tee, a 6 year old little girl with pneumonia who presented to ED 2 days ago on the advice of her GP and has since been admitted to the wards.

She's had a slew of symptoms since last Tuesday, about a week ago, that included fevers, vomitting, diarrhea, abdo pain, cough, sore throat, coryzal symptoms and hallucinations. I'll go through each in more detail..

Her coryzal symptoms started late Monday night with what her mom described as "the sniffles." By Tuesday, she was having fevers in the high 39s to 40 degrees and this lasted through the rest of the week despite being given panadol and panamax. Tee also hallucinated Tuesday night, mistaking bead curtains for the plaits of a little girl and she got agitated, whining that the little girl shouldn't be allowed into bed with her. This was prolly attributed to her high temperatures. She's had 2 episodes of vomitting since admission, bringing up thick clear phlegm. no blood, particles or food and there was no pattern to the vomitting; she didn't vomit after every meal or anything like that. Tee's had 1 - 2 bouts of diarrhea but her bowel motions have since returned to normal. Her abdo pain was her major complaint. It started out generalized but localized into left hip pain 4 days ago. A day later, it had become left shoulder pain. pain so bad it caused Tee to scream herself to exhaustion everytime she had an "attack" of the pain. Throughout all this, Tee has had a dry persistent cough and a sore throat that developed a few days after the initial fever. She has seen 3 different GPs throughout the week and was prescribed antibiotics by the 2nd GP, who suspected pleuricy. The first GP thought it was a viral self-limiting illness and the 3rd GP sent her to ED when her mother wanted a referral for an xray of Tee's shoulder.

Tee's been more tired and listless than usual. She's sleeping 3 - 4x during the day but is also sleeping through the night unless she's woken up by the pain along her left side. Her appetite's been less than usual, eating only jello and light snacks. She's well hydrated with her choice of water, juice and sprite with her mother making sure she's sipping one of them everytime she checks on her.

Besides breaking her collarbone last year at this time, Tee's had no other relevant surgical history. According to mom, she's had bowel problems since she was born and had to be on parachoc. Nowadays, she gets abdominal pains about once a month and these are relieved by a dose of parachoc. Tee's been also seeing a counsellor at the Wallsend branch of Kaleidescope regarding separation issues ~ she had trouble adjusting to the seperation of her parents about 12 months ago and refused to leave her mother, becoming clingy. Her mother didn't elaborate, stating that she didn't want to talk about this in front of Tee so I didn't pursue this any further.

The pregnancy was uneventful. Her mother was involved in a motorbike accident when she was 5 weeks pregnant and was given oral painkillers and IV morphine for a few days. No other medications were taken during the rest of the pregnancy and no complications such as gestational diabetes or pre-eclampsia developed. Tee was 10 days overdue and had to be induced. Forceps had to be used to aid in her delivery but she was well. Her mother didn't know her Apgar scores but remembers that Tee passed her baby check. (i forgot to ask for birth weight even though i had scribbled it down and circled the thing). Tee's not normally on any sort of medication, has no known allergies and her vaccinations are up to date. She's currently on IV penicillin and oral antibiotics 3x a day while in hospital.

Tee's now attending first grade and is near the top of her class. She gets along fine with her classmates and there haven't been any reports of disruptive or abnormal behavior. At home, she lives with her mom and younger sister who's 4. She sees her dad during the weekends.

On physical examination.. well when I first saw Tee, she was a well.. well-perfused looking girl who was sitting up in bed playing with all her birthday presents. She was obviously better from what her mom had described her to be last week because I saw her get up several times to answer phone calls bearing birthday wishes throughout the interview. Her vitals... they were all normal. BP was 96/68, pulse was 96bpm, last recorded temp on charts was 36.2 degrees, resp rate was 20. Her hydration status was normal ~ no signs of dehydration like sunken eyes and her capillary refill was less than 2 seconds. Her height and weight were both between the 50th and 75th percentiles, showing normal and symmetrical growth. Her head circumference fell just below the 50th percentile for her age but that's also considered normal.

I started out by looking at her hands ~ no clubbing that would indicate some sort of chronic disease, palmar creases normal, weren't pale so she's not anemic. capillary refill was normal as I've said. Then I moved up to her head. Eyes were fine ~ red and pupillary reflexes present. Then I looked in her ears ~ no signs of inflammation seen to suggest otitis media. She also hadn't complained of sore ears so OM is unlikely. Her nose was fine.. no deviated septum or anatomical abnormalities. When I looked in her mouth, I could see whitish stuff on her tonsils but couldn't get a good look because she was trouble keeping her mouth open and tongue out and was also coughing. Her parotids and lymph nodes weren't swollen, she had no tracheal tug, accessory mm use or other signs of respiratory distress when I looked. Her trachea was midline, chest was normal ~ no structural abnormalities. When I percussed, I could elicit an area of consolidation on her lower left lobe at the back. On ausculatation, I heard bronchial breath sounds at her upper left lobe in front. Air entry seemed to be decreased on her lower left lobe when compared to the right lobe. No vocal fremitus or resonance could be elicited.

Next, I had a quick look at her abdomen. It was soft, non-tender and wasn't distended...

by this point, murray had to cut me off and tell me to summarize cuz we were running out of time. so in summary, I saw Tee, a 6 year old little girl with pneumonia being treated with IV penicillin and oral antibiotics who is now on the mend.